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The Daily Scan

Last Updated: 8:55 AM EST

Medicare & Medicaid

  • Earlier this week, the Centers for Medicare & Medicaid Services (CMS) released an evaluation report for the first performance year of the Innovation Center’s Next Generation Accountable Care Organization (ACO) Model showing promising early results. Results demonstrated the positive outcomes in terms of quality and costs when providers are responsible for managing to a budget. For the 2016 performance year, the Next Generation ACO Model generated net savings to Medicare of approximately $62 million while maintaining quality of care for beneficiaries. As part of CMS’s recent “Pathways to Success” proposal, CMS proposed taking many principles from the Next Generation ACO Model and adopting them more broadly for ACOs in the Medicare Shared Savings Program. “These results provide further evidence that ACOs succeed under two-sided risk,” said CMS Administrator Seema Verma. (CMS.gov)

  • The South Dakota Department of Social Services (DSS) has submitted a request to the Centers for Medicare and Medicaid (CMS) for a five-year Medicaid 1115 demonstration waiver. The demonstration is a pilot project proposing work requirements for able-bodied adults who are enrolled in Medicaid through the Low Income Parent coverage group. The program, called South Dakota Career Connector, will be administered by DSS in partnership with the Department of Labor and Regulation (DLR). The program includes intensive employment and training services and skill building opportunities offered through DLR and offers a variety of pathways and supports for recipients to actively participate and maintain health care coverage. Individualized plans will address current barriers to employment. “The goals of the program are to improve participants’ health, encourage the development of healthy habits and empower participants to be successful in today’s workforce,” said state Department of Social Services Secretary Lynne Valenti. (DSS.SD.gov)

  • The Washington Post reported yesterday that the Trump administration will pay New York and Minnesota close to half a billion dollars this year after the two states sued over lost federal funding for programs that provide health care to tens of thousands of low-income residents. The two states are the only ones in the country to create “Basic Health Programs,” an option for states created by the Affordable Care Act. Under such programs, people earning between 138% and 200% of the federal poverty level -- the population earning slightly too much to be eligible for Medicaid -- receive their health coverage from the state. The programs have been financed with federal funds since the ACA was passed in 2010. Under the law, the federal government is charged with paying 95% of the funds it would have directed toward subsidies for those needing help with insurance premiums -- as well as toward the cost-sharing reductions (CSRs) the government promised insurance companies for offering lower-price plans through the individual marketplace. That system worked fine for both states until the Trump administration last fall eliminated CSRs, thus reducing the amount of federal funding those states received to cover people in their Basic Health Programs. (Article: WashingtonPost.com, Order: Medicaid.gov)


  • The husband and wife co-owners of a Miami pain management clinic and a patient recruiter pleaded guilty today to conspiracy to distribute controlled substances for their participation in a scheme to unlawfully distribute thousands of pills of oxycodone. David Bosch and Tania Sanchez owned and operated East Medical Office Inc. (“East”), purportedly a pain management clinic in Hialeah, Florida. Bosch incorporated the cash-only clinic in April 2017 and ran it with Sanchez until their arrests on May 3. Bosch and Sanchez hired a physician to be the purported medical doctor of East because they knew the physician would write prescriptions for oxycodone without regard to medical necessity. They paid the physician $125 for each prescription. They also conspired with patient recruiters and drug diverters to distribute oxycodone. Bosch introduced a purported patient recruiter to Machado and Abreu and informed the recruiter that the recruiter could make money by obtaining oxycodone pills from medically unnecessary prescriptions from East and then selling the pills. Additionally, Sanchez filled out fraudulent medical paperwork for purported patients. Abreu recruited her own patients to visit East. Abreu brought to East at least 18 individuals who paid approximately $250 for each purported “medical consultation” in order to receive controlled substances, especially oxycodone, that were not medically necessary. Abreu’s recruits received prescriptions for at least 5,000 tablets of oxycodone 30 mg. Abreu also offered to purchase pills from another individual whom she believed was a patient recruiter at East. (Justice.gov)


  • The U.S. Food and Drug Administration announced yesterday it has warned four more online networks, operating a total of 21 websites, illegally marketing potentially dangerous, unapproved, and misbranded versions of opioid medications, including tramadol. The warning letters issued by the FDA to each of the networks state that they must immediately stop illegally selling these products to American consumers. “The illegal online sale of opioids represents a serious risk to Americans and is helping to fuel the opioid crisis. Cutting off this flow of illicit internet traffic in opioids is critical, and we’ll continue to pursue all means of enforcement to hinder online drug dealers and curb this dangerous practice,” said FDA Commissioner Scott Gottlieb, M.D. (FDA.gov)

Private Sector

  • Pfizer, Inc. filed a Citizen Petition on Monday requesting that the Food and Drug Administration (“FDA” or “Agency”) "issue guidance to ensure truthful and non-misleading communications by sponsors concerning the safety and effectiveness of biosimilars, including interchangeable biologics, relative to reference product(s)" as a follow-up to the FDA's BioSimilar Action Plan released last month. In the petition, Pfizer explained: "Issuing guidance on communications about these products would be an important contribution toward eliminating unnecessary barriers to successful market success for biosimilars, including, in the future, interchangeable biologics. Additionally, such guidance is critical to ensuring a fair and level playing field for competition in the interests of patients and our healthcare system."

  • Bridge Connector, which delivers streamlined integration solutions for healthcare organizations, finished their $5.5 million Series A round, led by Tampa-based emerging-technologies firm Axioma Ventures LLC, bringing the company’s total investment to $10 million in funding. The funding will help further expand Bridge Connector’s sales, marketing, and client-services efforts, as well as accelerate the platform’s growth in closing the industry-wide interoperability gap. A press release explains: "Since the early days of electronic medical records, the lack of interoperability has been a major challenge in healthcare. Integration of disparate systems between medical devices and electronic health records can be both time-intensive and costly, and can lead to dangerous medical errors if done incorrectly. Although some healthcare organizations have succeeded in integrating their systems to streamline data, it has been a slow, expensive process that is also difficult to maintain." "Between $10 million in total funding and Axioma's expert counsel, we can aggressively pursue our mission to conquer the interoperability challenge with better technology, strategic partnerships, and smart hires," said David Wenger, CEO and founder of Bridge Connector. (BridgeConnector.co)

#Medicaid #Medicare #Litigation #Regulation #PrivateSector


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